2.0 Analysis 2.1 Introduction As there were no survivors or witnesses, there is insufficient information or evidence as to the precise cause of the vessel's loss. 2.2 Risks of Operation Although the PATRICK ELIZABETH was reported to be sound, well maintained and prudently operated, any small vessel employed offshore in exposed waters is operated at some risk. An insignificant or minor deficiency which, in normal operations, is not apparent or gives no cause for concern can, in extreme conditions, initiate a sequence of events which could rapidly culminate in the loss of the vessel. However, the operator was known to be safety- conscious and the vessel's SIC 29 had no outstanding work to be done. Because there was no pre-trip quota for the fish being caught, the vessel was not under economic pressures to remain at the fishing grounds after the storm warning was broadcast and did not do so. 2.3 Course Steered by the Vessel from the Fishing Grounds The course steered by the vessel from the fishing grounds is unknown; however, the most probable course to Bay Bulls from the positions given by the skipper before the tragedy would have been about 235 True (T). With northerly winds, the storm conditions would have been on the vessel's starboard side. The skipper had indicated that, should the weather deteriorate, he would lie-to with the vessel, but it is not known if this was done. The direction in which the vessel was heading when she was overcome is unknown. 2.4 Time and Position of the Distress The time and position of the distress are unknown; however, it must have occurred after 2200, 12 October 1994, at which time the skipper reported by radio that everything was fine. The ETA of 0600 the next morning given at 2200 did not agree with the skipper's estimate that the vessel was six hours out from Bay Bulls. The contradiction did not significantly affect the calculation of the vessel's LKP. CANSARP plots were based on the last-known, mid-point and destination positions. It could reasonably be expected that the vessel could make five knots in beam seas on a course of 235(T). Once debris had been sighted, CANSARPs were adjusted, taking into account the back drift rate of the various debris and of the liferaft. According to the adjusted CANSARP, the most likely position in which the vessel was overwhelmed was 4740'N, 05154'W. 2.5 Debris Analysis of the debris recovered during the search appears to confirm that the vessel was lost as a result of catastrophic structural damage and eventual disintegration. Examination of the debris, however, did not reveal sufficient evidence to determine the chain of events which led to the vessel's loss because some indications were contradictory. While the fastenings of the wheel-house top were bent in a manner consistent with the top having been forced up and over from port to starboard, this is in the opposite direction (from the lee to the weather side on a course of 235(T)) from which damage from waves could be expected. 2.6 Radio Communications The vessel's radio equipment functioned satisfactorily at 1500 and at 2200 on 12 October. Because neither a MAYDAY message nor a signal from the radiotelephone automatic alarm was received, it is likely that the damage which overcame the vessel was catastrophic and occurred suddenly, without warning. Given the extent of this damage, it is likely that the crew was unable to transmit a call for assistance. 2.7 Emergency Position Indicating Radio Beacon (EPIRB) The PATRICK ELIZABETH did not carry an EPIRB and was not required to by regulation. Because it is likely that the crew did not have time to send a distress message, the transmission from an EPIRB could have automatically alerted SAR authorities at the onset of the distress and might have increased the crew's chance of survival. 2.8 Abandonment Given that the wreckage of the vessel's liferaft and dory showed no sign of these craft having been occupied, all indications are that the vessel was overcome by the wind and waves and broke up. It is also probable that the suddenness of the casualty prevented the crew from safely abandoning the vessel. 2.9 Stability Because of the extent of the reconstruction and alterations to the PATRICK ELIZABETH, no comparable vessel exists from which stability information might be used to approximate the stability condition of the vessel at the time of her disappearance. Reportedly, there were 100 nets and 3,200 kg of iced turbot on board. Because the vessel had previously carried catches of 25,000 kg and more than 150 nets on the afterdeck, it is unlikely that the amount and distribution of the fish, ice and nets carried on her final voyage had a deleterious effect on the vessel's stability. Tank liquids which were reportedly 70 to 80 per cent depleted during the return voyage may have created a free surface effect. However, it is not known how this may have affected the vessel's transverse stability or from which tanks the consumables were drawn. 2.10 Possibility of a Collision It is unlikely that the vessel's loss was caused by a collision because there was nothing on the recovered debris to indicate that the vessel had struck another object or vessel. The fact that no other vessel traffic was known to be in the immediate area strengthens this hypothesis. 3.0 Conclusions 3.1 Findings The loss of the PATRICK ELIZABETH with her crew of five occurred in the approximate calculated position of 4740'N, 05154'W, north-east of Bay Bulls, between 2200, 12 October, and 1746, 13 October 1994. Examination of recovered debris indicates that the vessel was lost as a result of sudden catastrophic structural failure and disintegration in severe storm conditions. Although the vessel was fitted with a marine radiotelephone equipped with an automatic emergency alarm, no transmission of a distress was received. The vessel was not required by regulation to carry an Emergency Position Indicating Radio Beacon (EPIRB) nor was one on board. The vessel's liferaft was recovered and found to be in good condition and operational. There is no evidence that the crew succeeded in abandoning the vessel or that the vessel's liferaft or dory had been occupied. There is no evidence to suggest that the vessel was lost as a result of a collision. There is insufficient data to carry out a detailed stability analysis but, compared with previous voyages, the vessel was not overloaded. Tank liquids, depleted during the voyage, may have created an unknown free surface effect which could have adversely affected the vessel's transverse stability. There is no requirement for the vessel to carry anti-exposure worksuits or immersion suits for each member of the complement. 3.2 Causes There is insufficient information or evidence as to the precise cause of the vessel's loss. However, it appears that the vessel was quickly overwhelmed by wind and waves, and that the crew had insufficient time to send a distress message or abandon the vessel safely. 4.0 Safety Action 4.1 Action Taken 4.1.1 Carriage of Emergency Position Indicating Radio Beacons (EPIRBs) The PATRICK ELIZABETH did not carry an EPIRB and was not required to do so by regulation. EPIRBs have been instrumental in saving lives in recent marine occurrences. Consequently, following the sinking of the tug PATRICIA B. McALLISTER in the Gulf of St. Lawrence (TBS Report No. M91L3010) and the resultant loss of lives associated with delayed rescue operations during abandonment at sea, the Board recommended that: The Department of Transport encourage the use of Class I EPIRBs by all vessels that transit or operate beyond the limits of coastal harbours. (M93-10, issued September 1993) Subsequently, Ship Safety Bulletin (SSB) No. 1/94 was issued recommending to mariners, inter alia, to install EPIRBs for better information and identification of casualty location.